Healthcare

'Hard to Reach’ groups

Groups can be hard to reach for all sorts of reasons (language, minority groups and so on), but it is odd to think that there exists a huge group of which many of us will know that is also hard to reach.

I would like to think that in all areas, governments and local authorities are working to diminish the difficulty of first reaching them and secondly improving their lot. The Equalities Act in 2010 has done much to give a strong focus to this work, despite pressures elsewhere on money and staff to deliver the improvements.

Strangely, the hard to reach group featured in today’s article is going on for two million strong, most of us will know at least one and they are vital to the welfare of many of our most vulnerable people. I am talking of the Social Care workforce - bigger than the military, the police and the motor trade put together according to a report from the workforce monitor! And yet, incredibly, hard to find, talk to and develop, except in small disparate groups.

When I joined this workforce myself in the late sixties, the vast majority of care provision was delivered by the local Council. Each year, a publication of Social Trends was published which gave data on a range of things including the numbers in the workforce. At that time it was possible for the Minister of Health to talk to that workforce indirectly but very effectively through one hundred and fifty odd local authorities. Advice, guidance and regulation all arrived via a bank of government circulars - and we read them and applied them. All staff were on reasonable wages with a good pension, trade union support and with in-service training for progress. Then came the 1980’s.

There was strong belief that there was too much public service that was dyed in the wool and resistant to change and improvement. There was also a strong view that it was expensive and people outside the Councils would be able to provide all of these things just as well, more creatively and for less money. Thus began the introduction of competition with public authorities having to subject some of their services to Compulsory Competitive Tendering (CCT). In healthcare, an early service to be tendered was cleaning services at St James Hospital, Leeds. The poor way that staff were transferred led to improvements in the process but no change in the direction of travel.

Community Care: Agenda for Action, a review and publication led by Sir Roy Griffiths, a Director at Sainsbury’s suggested a range of provision - public, private and voluntary to meet the range of needs. This would offer choice to those who could buy better but a guaranteed quality at the minimum level for everyone. The period saw massive increases in the numbers of private care homes in which an older person could simply present themselves to a care home, declare their need for care and hand over their money or allowance books to be rolled together to cover their fees. Councils began to regulate what they were buying from 1984 but only had themselves to measure against.

The NHS and Community Care Act in 1990 established the process more tightly and put the brakes on the free for all that had been the order of the day prior to it. Rising numbers of older people were needing support and would prefer to stay at home, although demand for care was such that bed numbers in care homes continued to rise. The anxiety of families about their ageing relative often culminated in a care home placement as that was deemed to be the safest solution, regardless of the wishes of the person.

As financial pressures rose, the move to externalise Council provision gathered pace. Regulation moved from the Councils and in 2000, what was sometimes called the ‘modernising quartet’ of the National Care Services Commission (NCSC), the Social Care Institute for Excellence (SCIE), a staff training organisation TOPSS and the General Social Services Council (GSCC) was formed to look after this new system. The first three continue to this day as CQC, SCIE and Skills for Care but the GSCC, set up to register and regulate the workforce was deemed too difficult and too expensive. Only qualified Social Workers were then required to register to practice.

Similar bodies in Scotland (SSSC), Wales (CCW) and Northern Ireland (NISSC) continued the work and have succeeded in developing registration and staying connected with their particular social care workforces allowing the Care Council to know them, support them and hold them to account for any shortcomings and making the Care Council better able to protect those members of the public who need it. Next year Social Care Wales will form to combine all four functions noted above.

In England the story is different. Following the bank crash in 2008, one of the few areas of employment that have continued to grow has been in the care sector. In fact, it continues to be short of good staff especially Registered Managers and depends quite heavily on migrant workers.

In November 2014, the Catholic Bishops’ Conference ran a day conference entitled ‘Do Catholics have a Samaritan gene?’ The keynote speakers were Fr Gerry Arbuckle, a Marist priest from Australia who has written extensively on health and care and Fr James Hanvey SJ who provided clear and helpful theological insights into the function our work.

This conference was driven by a desire to understand whether a Catholic is more likely than other people to be in the health and social care areas of employment. A freedom of informatio request made to the NHS Trusts of England and Wales last year revealed a high proportion of Christian staff but it was impossible to determine what proportion were Catholic (practising, lapsed or collapsed).

Research into the Catholic community by Stephen Bullivant of St Mary’s University, Strawberry Hill in 2014helpfully showed that there was a higher proportion of Catholics working in Health and Care compared to the general presence of Catholics in the population as a whole.

So, if we know they are there, the challenge was to reach and engage with them. People around us at the Bishops’ Conference suggested they were in need of help for a variety of reasons to do with ethics, conscientious objection and employment rights. Higher up the workforce in Health and Social Care, staff are members of Colleges, trade unions and may additionally have professional indemnity cover to help and some have expressly stated that they keep their faith and work apart for this purpose.

At the lower end and numerically the majority by far (76% in adult social care) will be mostly women (82%), heavily black and minority ethnic, part time, minimum wage earners, unsupported and underrated. More than a third who work for other services that are outside the regulation of CQC and are not included here.

It is always a shock to people to discover that the Veterinary Assistant that takes care of your pet is still better regulated in England then the person who looks after your elderly or disabled relative or friend!

This massively increased workforce is spread over more than twenty seven thousand regulated services in 18,000 organisations (plus an uncounted number of unregulated ones) across the country, about 85% of which are privately owned, about 11% in the voluntary, now called not for profit, sector and the last 3-4% still with the Councils, providing mostly hospital discharge and short term emergency support. And that is only England.

When we manage to talk to individuals in the work they tell us they don’t have time or spare money to be interested in issues beyond their immediate care environment but as a series of Panorama exposes have shown, these very isolated and low level people can suddenly find themselves held to account for the whole sector to the viewing public. This group of workers is relatively powerless and they serve people who in these relationships can be even more powerless.

The CQC annual publication ‘State of Social Care’, reported that 400,000 fewer people had receive Council funded support in 2014/15 compared to 2009/10. This is because of a 37% reduction in funding for this work over the period. Any pressure on community support systems usually backs quickly up on health services and that seems apparent with an NHS deficit in Trusts of £800 million last year.

Those people didn’t suddenly disappear and we have to assume they are either making their own arrangements for care and paying for it fully or they are managing with family help. As Christians, what should give us pause are those who have no family and no money and still have the need of support. The Home Care body, UKHCA asserts there are 1.6 million people in the UK with unmet needs. People with Mental ill health are even worse off, representing 23% of the burden of disease in the health system but only attracting 11% of the funds!

Care workers historically were confident, competent and capable, often advocating on behalf of the people they served to those in positions of power. We can no longer be sure of this. Our best hope of connecting Catholic Social Care workers up to each other to restore some of that confidence is through parishes and up to the Bishops’ Conference. Maybe a census of health and social care workers in our parishes would be a start?